Pancreatitis

1. Acute Pancreatitis By: Amina A. Al- Qaysi

2. Objectives Introduction Definition Epidemiology Aetiology & Pathogenesis Signs & Symptoms Investigations Management Complications Mortality

3. Pancreatitis Inflammation of the pancreatic parenchyma. Types: Acute: Emergency condition. Chronic: Prolonged & frequently lifelong disorder resulting from the development of fibrosis within the pancreas.

4. Acute Pancreatitis Definition: Acute condition of diffuse pancreatic inflammation & autodigestion , presents with abdominal pain, and is usually associated with raised pancreatic enzyme levels in the blood & urine. Reversible inflammation of the pancreas Ranges from mild to severe.

5. Epidemiology Acute pancreatitis accounts for 3% of all cases of abdominal pain among patients admitted to hospital in the UK. Affect 2 – 28 per 100 000 of population. It may occur at any age, peak incidence is between 50 and 60 years. Women are affected more the men, but men are more likely to suffer recurrent attacks.

6. Etiology 80% of the cases are due to gallstones & alcohol. The remaining 20 % of cases are due to: Congenital: Pancreatic divisum Metabolic: Hyperlipidemia , Hypercalcemia . Toxic: Scorpion venom Infective: Mumps, Coxsackie B, EBV, CMV.

7. 5. Drugs: Azathioprine , Sulfonamides , Steroids, Thiazides , Estrogens. 6. Vascular: Ischemia, Vasculitis (SLE, PAN). 7. Autoimmune: Hereditary pancreatitis. 8. Traumatic. 9. Miscellaneous: CF, Hypothermia, Periampullary Tumors . 10. Idiopathic.

8. Mnemonic for the causes of Acute Pancreatitis: ‘I get smashed‘ I diopathic G allstones E thanol T rauma S teroids M umps A utoimmune S corpion / S nakes H yperlipidaemia / H ypercalcaemia E RCP D rugs

9. Biliary Pancreatitis: Common channel theory Incompetent sphincter of Oddi Obstruction of the pancreatic duct

10. Alcoholic Pancreatitis: - Direct toxic effect on the pancreatic acinar cells - Stimulation of the pancreatic secretion - Constriction of the sphincter of Oddi

11. Symptoms Upper Abdominal pain, sudden onset, sharp, severe, continuous, radiates to the back, reduced by leaning forward. Generalized abdominal pain, radiates to the shoulder tips. Patient lies very still. Nausea, non- projactile vomiting, retching Anorexia Fever, weakness

12. Signs Distressed, moving continuously, or sitting still Pale, diaphoretic. Confusion Low grade fever Tachycardia, Tachypnea Shallow breathing Hypotension Mild icterus Abdominal distension ( Ileus , Ascites ) Grey Turner’s sign, Cullen’s sign, Fox’s sign Rebound tenderness, Rigidity Shifting dullness, reduced bowel sounds

13. Cullen’s Sign Grey Turner’s Sign Fox’s Sign

14. Panniculitis Subcutaneous nodular fat necrosis Tender red nodules Usually measures 0.5 – 2 cm Usually over the extremities

15. Differential Diagnosis Perforated viscus (DU) Acute cholecystits , Biliary colic Acute intestinal obstruction Esophageal rupture Mesenteric vascular obstruction Renal colic Dissecting aortic aneurysm Myocardial infarction Basal pneumonia Diabetic ketoacidosis

16. Investigations Should be aimed at answering three questions: Is a diagnosis of acute pancreatitis correct ? How severe is the attack ? What is the aetiology ?

17. Investigations Blood tests: Complete Blood Count Serum amylase & lipase C-reactive Protein Serum electrolytes Blood glucose Renal Function Tests Liver Function Tests LDH Coagulation profile Arterial Blood Gas Analysis

18. Serum Amylase: Sensitivity: 72% Specificity: 99% Released within 6-12 hours of the onset, & Remains elevated for 3-5 days . Elevation ˃ 3X normal is significant. Undergoes renal clearance. After its serum levels decline, its urinary level remains elevated. Its level doesn't correlate with the disease activity.

19. Serum Lipase: More pancreatic-specific than s. Amylase. Sensitivity: about 100% Specificity: 96% Remains elevated longer than amylase (up to week). Useful in patients presenting late to the physician. S. Amylase tends to be higher in gallstone pancreatitis S. Lipase tend to be higher in alcoholic pancreatitis

20. Imaging Investigations: Plain erect chest X-ray: not diagnostic on pancreatitis, but to rule out other D/D Pleural effusion, diffuse alveolar infiltrate (ARDS)

21. Sentinel Loop Sign

22. Colon cut-off sign

23. CT Scan: not indicated in every patient, only in: Diagnostic uncertainty. Severe acute pancreatitis. Clinical deterioration, with multi-organ failure, sepsis, progressive deterioration. Local complications occurs (fluid collection, pseuodocyst , pseudo-aneurysm).

24. Axial CT Scan: Peripancreatic stranding (arrow) . Multiple gallstones in the gallbladder

25. Contrast-enhanced CT: acute necrotising pancreatitis. Pancreatic area of reduced enhancement, peripancreatic edema and stranding of the fatty tissue

26. Pancreatic pseudocyst occupying the head of the pancreas. The pancreatic duct ( arrow ) is dilated

27. CT Severity Index = Balthazar Grade + Necrosis Score

28. MRCP

29. Endoscopic Ultrasound, MRCP: CBD stones detection, assessment of pancreatic parenchyma. Not widely available. ERCP: CBD stones identification & removal. Urgent ERCP in severe acute gallstone pancreatitis & signs of ongoing biliary obstruction & cholangitis .

30. ERCP

31. ERCP in Acute Pancreatitis

32. Biliary sphincterotomy with stone removal

33. Goals of Treatment Aggressive supportive care Decrease inflammation Limit superinfection Identify and treat complications (of pancreatitis & its treatment) Treat cause if possible

34. Conservative Management Gain IV access, obtain blood sample, rapid fluid resuscitation & electrolytes replacement. Give analgesics (IM pethidine ). Give Anti-emetics. Keep the patient NPO (until pain free/2-3 days). NGT insertion to relieve vomiting.

35. Urinary catheterization is done. Monitor the vital signs.

36. Injection Ranitidine 50 mg IV 8 hourly, or Omeprazole 40 mg IV BD. Somatostatin or octreotide (pancreatic secretions inhibitors). Respiratory support: oxygen supplementation, or Venti mask ICU admission if severe acute pancreatitis.

37. Role of Antibiotics Prophylactic antibiotics have shown No decrease in mortality in severe acute pancreatitis. Antibiotics are justified if: Gas in retroperitoneal space Needle aspiration of necrotic material confirms infection Sepsis CRP of ˃ 120 mg/L Peri -pancreatic fluid collection Organ dysfunction APACHE II Score of ˃ 6

38. Operative Management Surgery has no immediate role in acute pancreatitis. Aggressive surgical pancreatic debridement ( Necrosectomy ) should be undertaken soon after confirmation of the presence of infected necrosis. Pseudocyst : Cystogastrostomy , Cystodudenostomy , Roux-en-Y cystojejunostomy .

39. Complications

40. Complications Systemic Complications: Cardiovascular: Shock, Arrhythmias, Pericardial effusion Pulmonary: Basal atelactasis , pleural effusion, ARDS Renal: ATN, Renal failure Haematological: DIC Metabolic: Hypocalcemia , Hyperglycemia , Hyperlipidemia GIT: Ileus Neurological: Confusion, Irritability, Encephalopathy Miscellaneous: Subcutaneous fat necrosis, Arthralgia

41. Local Complications Acute fluid collection: Occurs early in the course of acute pancreatitis Located in or near the pancreas, the wall encompassing the collection is ill defined, the fluid is sterile. Most of such collections resolve, & no intervention is necessary unless a large collection causes symptoms or pressure effects, in which case it can be percutaneously aspirated under ultrasound or CT guidance. Transgastric drainage under EUS guidance is another option. An acute fluid collection that does not resolve can evolve into a pseudocyst or an abscess if it becomes infected.

42. Pancreatic Pseudocyst : Wall formed by granulation tissue & fibrosis typically presents as abdominal pain, abdominal mass, & persistent hyperamylasemia in a patient with prior pancreatitis.

43. Transgastric Endoscopic Pseudocyst Drainage

44. Sterile and infected pancreatic necrosis: Diffuse or focal area of non-viable parenchyma, typically associated with peripancreatic fat necrosis. These areas can be identified by an absence of contrast enhancement on CT. They’re sterile to begin with, but can become subsequently infected, due to the gut bacterial translocation. Sterile necrotic material should not be drained or interfered with. If the patient shows signs of sepsis, then one should determine whether the necrosis is infected.

45. Mortality Mild acute pancreatitis: Mortality rate of 1% Severe pancreatitis: Mortality rate of 75-90% Overall mortality rate of 15-20% First week of illness -> MODS Subsequent weeks -> infection

46. References Bailey’s & Love’s Short Practice of Surgery, 25 th Edition, Page 1138 – 1146. Essential Surgery, Burkitt , 4 th Edition, Page 380 – 388. Robbins & Cotran Pathologic Basis of Disease, 8 th Edition. http://www.aafp.org/afp/2007/0515/p1513.html http://www.aafp.org/afp/2000/0701/p164.html